How to introduce quality measures that are useful for providers

April 19, 2024 - In the push toward value-based care and incentivized quality measures, providers have been left with a long, complicated to-do list. But the industry can do better, according to Brad Ryan, MD, chief growth officer at NCQA.

In 2017, CMS introduced an entire initiative to reduce the burden of quality measurement on providers. The Meaningful Measures Initiative has reduced the amount of time that stakeholders worked on quality measurement by 3 million hours. Nevertheless, some research has indicated that value-based care efforts such as CMS's Medicare’s Merit-based Incentive Payment System (MIPS) have increased administrative burden for providers, including quality measure reporting, leading some organizations to call for an end to specific value-based care programs. All of this occurs at a time when the industry is also moving toward digital quality measures, a transition which carries its own challenges and opportunities.

Ryan discussed the transformation happening in quality measures. With the ongoing advancements in technology, there is an opportunity to reimagine quality measures in a way that gives more weight to the physician experience. Ryan challenged the idea that the value-based care transition is a spectrum and suggests that instead it is a transformation. He argued that meaningful data should focus on areas with high variability in care or cost. It should also reflect the nuances of individual populations and their specific care needs.

Brad Ryan, MD:

There's some, let's call it, traditional wisdom in value-based care that there is a spectrum from totally fee-for-service to totally capitated risk. It's actually not a spectrum when we talk to organizations who are making that journey. It's a transformation.

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Kelsey Waddill:

Welcome to Season 2 of Industry Perspectives, coming to you from HIMSS 2024 in Orlando, Florida. I am Kelsey Waddill, multimedia manager and managing editor at Xtelligent Healthcare. For providers, digital quality measure adoption and the ongoing shift to value-based care in the healthcare industry often simply mean more tasks to add to their plate. How can policymakers, payers, and other stakeholders better align quality measures with the provider experience and what needs to change about communication around quality measure adjustments? I got to chat about these questions and more with Brad Ryan, chief growth officer at NCQA, which is one of the organizations leading the charge on quality measure transformation. Here's his answer.

Thank you so much for coming on to Healthcare Strategies and welcome to HIMSS. I know you're talking a lot this weekend--and for the last couple of years--about digital quality measures and then just there's a lot of change that happens in quality measures each year as we evaluate what is working, what is not working. So I was curious about the process behind just changing quality measures and what is really indicative of quality, how we make that decision, and then we can go from there.

Brad Ryan, MD:

Yeah. The digital quality transformation opportunity is not just about digital. Digital is a means to an end. And what's that end? Well, the measurement system that we have today was created in a time when we had limitations. We had limitations in the data that was readily available and consistently available, which was largely claims and payment data and, therefore, administrative in nature. We had limitations in the technology infrastructure that was available, and so we've established a process where we take measures out to the industry on paper and using people to interpret them. We're also limited by the fact that we were, at least at NCQA, we were rather narrowly focused on health plan measurement.

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And what's changed since all that was put in place is we've spent a lot of money and time, sweat and tears digitizing the clinical data in this country with the adoption of electronic health records. We have built a lot more technology infrastructure and interoperability and policy-driven standards that are changing the way we can share and exchange information, whether it's data or knowledge in this case, with things like CQL and FHIR. CQL meaning a way to express logic, like a measure in computer interpretable form so that you don't have to interpret it or read it. And then finally, we've recognized that the industry, as they try to shift from fee-for-service toward value, they're using measures like HEDIS in different contexts that aren't just for health plan measurement at the end of a period. They're using it for similar type measures in the provider space and accountable care in at-risk value-based contracts, and we can design something better. And digital is our way of addressing a bunch of those problems now that the art of what's possible is different.

And so the thing that we want to accomplish with this move to digital is really three big benefits to the industry. One, reduced cost, burden, time, dollars associated with the whole measurement enterprise. We can distribute measures as computer interpretable software, and we can collect data out of electronic systems. Two, support more of the quality use cases that fit around measurement, quality improvement, population management, analytics. And three, we can build better measures because we have that clinical data, we can build more relevant, meaningful measures to clinicians. They can have more complexity and patient specificity because they're software and don't have to be interpreted by everyone separately. And so we really have an opportunity to reimagine the kind of measures we build, who uses them, and how they get them.

Kelsey Waddill:

Thank you. Yeah, that's a great overview of a lot of the shift that's been happening over the last couple of years, and I know you've brought up both the health plans and the doctors. I know a lot of times with quality measures, we talk about it from the health plan perspective. But I am curious, especially [since] you have a physician background, just how has the provider community been adjusting to these shifts over the last few years and more presently, how would you recommend helping providers through these big changes that are occurring both through the digital quality measures, and then again, those kind of yearly updates that we do?

Brad Ryan, MD:

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To be honest, we as an industry have done a disservice to providers when it comes to quality measurement and the things that we've asked providers in their offices and their health systems and support structures to do. We've introduced a lot more charting requirements, a lot more manual recording of information. We have opportunities now to make the data collection much easier and much more the exhaust from delivering care. And that's not just with EHRs. That's part of the answer is: capture the right information in the right structure from the start, but also with developments and things like AI and NLP, natural language processing, where we can make the data collection process a lot easier and not put all that burden on physicians and providers.

The second big thing is we've introduced a ton of variation. Same provider, same patient population--they're measured many different ways by many different organizations on things that are very similar. So we have this huge opportunity of alignment, a smaller number of things that they're being measured on that are more meaningful and more consistent across all the different value-based contracts and incentive contracts that they want to enter into. And if we could just address those two things, we would make a huge leap forward with the provider community and their understanding of the purpose and the value of the quality enterprise. Beyond that, if we can really deliver on meaningful measures with new measure types that I'm talking about that resonate with providers and patients more than some of the limitations we've had in the past, I think we can really take the next step towards meaningful risk in value-based contracts.

Kelsey Waddill:

Yeah. I'd love to hear more about the meaningful data piece that you've been referencing a couple of times and how we ensure that the data is both assessing quality on a general level, but also like you mentioned, meaningful for providers and informing what they do. What goes into deciding what's meaningful and what's useful?

Brad Ryan, MD:

Well, several things. It's a great question. The first is recognizing that not all evidence and best practice of care is created equal when it comes to what's important in value-based contracts. So when patient populations, providers, payers decide that they want to incentivize quality, they have areas of focus that are usually a combination of high variability in the care that's delivered either in the quality of that care and the outcomes for the patients or the cost associated with that care. We can focus on those areas to start, and we've done some of that, but we've got big gaps in today's measurement system.

And there're some common areas that come up, but it's usual suspects of like cardio, metabolic, diabetes, cardiovascular disease, and those populations--we have some measures, but they're limited, and we could do a better job of asking the question, "how well are you taking care of this population of people and managing their risk?" They're specialty areas where there are high-cost, high-variable outcome patient populations where we don't have good measures today. So step one is picking the right areas and prioritizing by what people want to incentivize. Our measures, as good as they might be, and reflecting best practices, they're really only as good as incentives get put behind them. So we need to meet the market on what's important to those purchasing and receiving healthcare for value-based contracts.

The second big thing that we can do is get away from what I'll call "really broad brush"--sometimes we say it's like a sledgehammer as a tool rather than a scalpel--with the measures that we use where we ask really one question about a huge population. "Give me all these people except for those people, and did they get a colonoscopy?" It's good to get those colonoscopies, but can we reflect more of the nuances of individual populations and risk among those populations and the care that they need to receive? So can we think more holistically about a cancer population and did you screen for it? Did you follow up from that screening? Did you get those patients the appropriate care that was required? Did you catch their cancers earlier and did they do well with their treatment? That's a big set of questions that we can start to ask with more clinical data and more complexity in what we provide in terms of the measures and the scope of those measures.

Kelsey Waddill, MD:

So kind of zooming out a little bit, outside of Medicare Advantage, [we] still kind of have a long way to go with getting into value-based care, and as you said, tying these quality measures to actual financial incentives that are powerful and working. What's it going to take to get us there?

Brad Ryan, MD:

Finally, an easy one.

Kelsey Waddill:

Yeah, I know.

Brad Ryan, MD:

I'd say it's obviously very complex because it's a transformation and it's a transformation of a lot of different business models. That's one of the most important things to realize is there's some, let's call it, traditional wisdom in value-based care that there is a spectrum from totally fee-for-service to totally capitated risk, and that the transition looks like going across the spectrum. It's actually not a spectrum when we talk to organizations who are making that journey. It's a transformation, both a business model transformation and a clinical transformation in the way that they align their care delivery services and resources.

And that transformation, there's a chasm there. A lot of where we've gotten stuck is adding quality and incentives on a fee-for-service chassis that give people some upside, maybe even a little, small amount of downside risk, but we haven't really given them the great tools to go from that left side of the chasm to the right side of the chasm, which is meaningful, shared risk, population payment, etcetera. So the companies that are doing that, that are making that transformation, they say, "We need different quality instruments than the quality instruments that were built for the early part of the spectrum. We need better quality measures that give us credit for really taking on the care of a whole high-risk complex population. And our tools today are just too narrow to do that." So there are many things that have to happen, but as far as we from NCQA think about it, our role in that is giving them those better instruments and supporting the investment case to make the transformation by giving them a little reward.

Kelsey Waddill:

And when you talk about instruments, just to clarify, you're talking about quality measures specifically or what kinds of instruments are required?

Brad Ryan, MD:

Measures are one type of instrument. There are some others. So because it's a transformation, there's new capabilities required for organizations that want to make that leap, and there's not great ways for them to know what that roadmap should look like and what the target should be, when it comes to data sharing and data collection and analytics capabilities, when it comes to care management. Some things that have traditionally been more like payer functions and some things that have been more delivery system functions, they may change if you're an at-risk organization. And so giving them some of those tools to know what those things are. And we also do things like accreditation and recognition. Perhaps recognizing organizations that have built those capabilities is another type of instrument. So we think measures, we think standards, we think data as the types of quality content that we provide that helps people on the journey.

Kelsey Waddill:

Well, I think that's all the time we have, unfortunately, but thank you so much for those comprehensive answers, and hopefully we can have you on again sometime.

Brad Ryan, MD:

Yeah, thanks for having me.

Kelsey Waddill:

Listeners, thank you for joining us on Healthcare Strategies' Industry Perspectives. When you get a chance, subscribe to our channels on Spotify and Apple and leave us a review to let us know what you think of this new series. More Industry Perspectives are on the way, so stay tuned.